DSM IV DIAGNOSIS: POSTTRAUMATIC STRESS DISORDER
Axis I 309.81 Posttraumatic Stress Disorder
Axis V GAF = 30 (current functioning)
The above five axis diagnosis is based on the symptoms presented. Axis I, Posttraumatic Stress Disorder, is substantiated by the following criteria: (A) exposure to a traumatic event with both present: experience, witness, or confrontation with an event involving actual or threatened death or serious injury to self or other, and the response includes intense fear, helplessness, or horror; (B) the event is persistently reexperienced in one or more of ways, which in this case include recurrent and intrusive distressing recollections of the events with images, thoughts, or perceptions, recurrent distressing dreams about the event, acting or feeling as if the event was recurring (reliving with illusions, hallucinations, and dissociative flashback episodes), and intense distress at cue exposure, physiological reactivity on exposure to cues; (C) persistent avoidance of stimuli associated with the trauma and numbing of responses to include three or more not present prior to the trauma, which in this case include efforts to avoid thoughts, feelings, or conversations related to the trauma, efforts to avoid activities, places, or people that trigger remembrance of the trauma, markedly diminished interest or participation in important activities, feeling detached from others, restricted affect with lack of positive feelings, and sense of a short future; (D) persistent symptoms of increased arousal include two or more (not present prior to the trauma) which in this case include difficulty falling or staying asleep, outbursts of anger, hypervigilance, exaggerated startle response; (E) Disturbance is more than one month; (F) disturbance results in clinically significant distress or impairment in functioning (APA, 1994).
The client reports that he hasn't slept for twenty years (can't sleep or falls aslee...